Unresectable Cholangiocarcinoma: Comparison of Survival in Biliary Stenting Alone Versus Stenting With Photodynamic Therapy

Kahaleh, Michel; Mishra, Ravi Shankar; Shami, Vanessa M.; Northup, Patrick G.; Berg, Carl L.; Bashlor, Penny; Jones, Philip C.; Ellen, Kristi; Weiss, Geoffrey R.; Brenin, Christiana; Kurth, Barbara E.; Rich, Tyvin A.; Adams, Reid B.; Yeaton, Paul

doi:10.1016/j.cgh.2007.12.004

Cited by 174 publications

(122 citation statements)

References 56 publications

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“…More effective therapies for locally advanced cholangiocarcinoma are needed. Initial studies of photodynamic therapy (PDT) have been encouraging [13][14][15]. A randomized trial of stenting versus stenting plus PDT identified greater survival in the PDT group [16].…”

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confidence: 99%

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Aslanian

Jamidar

2011

Dig Dis Sci

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The majority of patients with cholangiocarcinoma present with locally unresectable disease and the median survival with radiation and chemotherapy is 7-12 months. The endoscopic palliation of inoperable hilar cholangiocarcinoma remains one of the more challenging cases for the biliary endoscopist. The endoscopist must define the anatomy without injecting contrast into ducts that will not be drained, achieve guide-wire access for unilateral or bilateral stent placement and determine what type of stent-plastic or self-expanding metal (SEMS), will best serve the patient to relieve pain and jaundice and prevent cholangitis.Raju et al.[1] present a retrospective review of 100 patients who underwent endoscopic plastic or SEMS placement for inoperable hilar cholangiocarcinoma. Patients were regularly followed to death or reintervention, and stent patency and survival were examined. In 48 patients uncovered (as expected due to the hilar location of obstruction) SEMS were placed, with plastic stents (at least one of which was 10 French) in the other 52 patients. The Bismuth Classification of lesions was similar between the groups. There was however, a greater number of Type 3 and 4 cases that received plastic stents (73.1% vs. 56.3%), potentially favoring a better outcome with SEMS. The technical success rate was high in both groups (95.8% vs. 94.2%). Bilateral stenting was performed successfully in 20/23 plastic stent patients and 5/5 SEMS. The SEMS group demonstrated significantly better stent patency (5.56 vs. 1.86 months) and required fewer re-interventions for stent obstruction (1.53 vs.4.6). The complication rate was similar in both groups (8.3% SEMS and 7.7% plastic) and there was a non-significant trend towards greater survival in the SEMS group (9.08 vs. 8.22 months). During the study time period, routine stent changes in patients with plastic stents were not performed; however, the median patency was only 1.5 months. No difference between the patency of straight and pigtail plastic stents was seen, nor was there a difference between unilateral and bilateral plastic stents or SEMS. All re-interventions were performed endoscopically, nine patients with plastic stents were converted to SEMS and plastic stents were placed within SEMS in four patients.The results of Raju et al. are similar to those of prior studies identifying less stent failure with the use of SEMS versus plastic stents for hilar tumors [2,3]. There is scant information in the way of randomized comparisons between plastic and metal stents. A study by Wagner et al.[2] is the only prospective, randomized study. Twenty patients were randomized between metal stents placed percutaneously or endoscopic stents placed by a combination of endoscopic-percutaneous technique. Perdue et al.[3] reviewed a multicenter database of 62 consecutivelyreported endoscopically-placed metal or plastic stents for hilar obstruction. Outcomes in favor of metals stents were reported in both studies.

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confidence: 99%

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Aslanian

Jamidar

2011

Dig Dis Sci

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“…36 PDT has been shown to have a significant survival benefit in patients with unresectable cholangiocarcinoma as well as a significant improvement in the quality of life after PDT and stenting. 37,38 Though other photosensitizers are now available, porfimer sodium is the most studied and the only photosensitizer approved by the FDA.…”

Section: Principle Of Photodynamic Therapymentioning

confidence: 99%

“…Staging can be performed with CT and/or MRI. 37 Resectability is usually defined according to the criteria of Vauthey and Blumgart. 39 Bismuth classification should be documented for all patients.…”

Section: Staging and Tissue Diagnosismentioning

confidence: 99%

Photodynamic Therapy for Cholangiocarcinoma

Talreja

Kahaleh

2010

Gut Liver

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Cholangiocarcinoma is the primary malignancy arising from the biliary epithelium, and it presents as jaundice, cholestasis, and cholangitis. Over 50 percent of patients present with advanced-stage disease, and the prognosis is poor with the survival measured in months even after biliary decompression. Palliative management has become the standard of care for unresectable disease, and this involves an endoscopic approach. Photodynamic therapy (PDT) involves the administration of a photosensitizer followed by local irradiation with laser therapy. The use of PDT for palliation of bile-duct tumors has produced promising results. Several studies conducted in Europe and the United States have shown that PDT produces a marked improvement in the symptoms of cholestasis, survival, and quality of life. This chapter summarizes the principle of PDT, the technique employed, and the published experience regarding PDT for cholangiocarcinoma. (Gut Liver 2010;4(Suppl. 1):S62-66)

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“…Based on the HTA report, 2 RCTs 9,10 and 2 nonrandomized studies 11,12 compared stenting alone with stenting plus PDT for cancer of the bile duct. The evidence suggested that survival increased when PDT was given along with stenting.…”

Section: Bile Ductmentioning

confidence: 99%

How Mainstream Medicine Sees Photodynamic Therapy in the United Kingdom

Bown

2012

J Natl Compr Canc Netw

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Although photodynamic therapy (PDT) has been used successfully to treat an assortment of different types of cancer, it has yet to reach the level of mainstream medicine on either side of the Atlantic. Unsubstantiated claims of PDT's efficacy in the past may be part of the reason for this. However, perhaps the main obstacle to PDT's endorsement by conventional medicine is the limited number of high-quality randomized controlled trials (RCTs) comparing it with relevant comparators for all meaningful outcomes, including effectiveness, safety, adverse events, quality of life, survival, and cost. Based on a Health Technology Assessment report on the current status of PDT and consultation with professional groups, specialist societies, and clinical study groups in the United Kingdom, this article explores the current clinical guidelines for use of PDT in cancer treatment and the dearth of supportive data from RCTs. (

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Unresectable Cholangiocarcinoma: Comparison of Survival in Biliary Stenting Alone Versus Stenting With Photodynamic Therapy

Cited by 174 publications

References 56 publications

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Photodynamic Therapy for Cholangiocarcinoma

How Mainstream Medicine Sees Photodynamic Therapy in the United Kingdom

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